BALTIMORE––Could it be the end of the yearly threat of a 26% cut in physician pay, as we know it?

Renal Physicians Association Director of Public Policy, Rob Blaser, thinks so. “We have never been anywhere close to repealing the SGR as we are right now. This is a big deal,” he told physicians and practice managers here during his annual legislative update at the Renal Physicians Association 2014 meeting. “There is a real acknowledgment [in Congress] that we have to fix this.” Questions still remain on the legislation, such as how to cover the $138 billion cost over the next 10 years, and how the second component of the fix—tying performance in with payment long term––will be developed. Blaser said the RPA and other groups are seeking federal funding to develop quality measures geared toward measuring performance under the new payment proposal. “Developing a clinical measure can cost up to $50,000 each,” he said.

A cooperative Congress

Blaser said one of the reasons why progress is being made on the SGR is that Congress lost what little respect it had in the public opinion polls while fighting over the debt crisis and funding Obamacare. That helped to bring them back on track and get more discussions and bills passed in a bipartisan way––if, and when possible. “Congress is actually playing well now” in the political sandbox, Blaser said. “Things have calmed down” and the legislative process is moving along as it should. “The fact that the SGR bills in both the House and Senate were all passed unanimously by members on both sides of the aisle acknowledges that everyone wants to fix the SGR and get it off the table,” Blaser said. While there are still some actions of political chicanery going on—like tying the SGR repeal to dropping insurance coverage mandates in the Accountable Care Act, the days of filibusting may be over – at least until after the 2014 elections.

Blaser covered a multitude of legislative and regulatory issues impacting nephrology, including the upcoming re-launch of the renal ACO, changes to the physician fee schedule and payment for interventional nephrology procedures, efforts to pass immunosuppressant drug legislation, and recent concerns over treatment of acute care injury patients in the outpatient setting.  Here are some of his comments:

  • On the accountable care organization ESRD demonstration model: “The bloom came off the ESCO rose” as nephrologists and dialysis providers started reading the fine print about the Comprehensive ESRD Care Model demonstration, Blaser said. Time will tell if the re-launching of the application process addresses nephrologists’ concerns about risk and rewards, including granting waivers, addressing CMS’s plan to rebase the cost after three years, and how the final quality measures that will be used by CMS to grade outcomes will look. 
  • On the lifetime immunosuppressive drug coverage legislation: “The good news is that no one disagrees on this,” said Blaser, but Congress needs a Medicare bill to carry the drug legislation through. The Congressional Budget Office is also supposed to re-score the cost based on the availability of genetic drugs. The House version of the bill now has over 100 sponsors.
  • On the 12% cut in the ESRD bundled payment: CMS has no plans to delay the inclusion of oral drugs into the bundle in 2016, said Blaser. Promises by Congress to fix the case-mix adjuster model, outlier policy, and use more current data for drug pricing should be and can be accomplished.
  • On the Medicare Fee Schedule for physicians: No review planned for Medicare’s Monthly Capitated Payment, and nephrologists saw some gains in the 2014 final rule. While efforts to rescind cuts in payments for interventional procedures were successful, CMS will continue to place these codes under scrutiny, Blaser said.
  • On moving to ICD-10 codes for medical services: No delay from the Oct. 1 deadline expected, despite efforts by the American Medical Association. The changes won’t be as complex for nephrology compared to other specialties, said Blaser.
  • On CMS’s Recovery Audit Program: This program is aimed at finding Medicare Part A & B overpayments on claims of health care services provided to Medicare patients.  The program has been rewarding for Medicare: the original demonstration that ran between 2005 and 2008 netted over $900 million in overpayments. But Blaser said the detective work has been put on “pause” for refinement––and to deal with a backlog of over 300,000 appeals by providers accused with overcharging.
  • On proposed changes to how certain drugs are listed under Part D drug plans: CMS agreed to scrap a controversial plan to lift the protected class definition on immunosuppressant drugs, which would mean part D plans would limit coverage to certain ones. “There was lots of fighting over this,” said Blaser. CMS acted quickly: the comment period on the proposal ended on Friday, March 7; by Monday, March 10, the agency had withdrawn it, he said.

 More coverage of the RPA Annual Meeting:

CMS CMO says to expect an "array of adjustments" in revised renal ACO demonstration rules